Liver Transplantation and Alcoholism Rehabilitation.

In the excitement of finding a remarkably high rate of first-year abstinence among his alcoholic liver transplant patients (Starzl et al. 1988), Dr. Thomas Starzl, the pioneer of transplant surgery in this country, commented to the press that liver transplantation might be the ultimate cure for alcoholism.(1) His study of transplanted alcoholic patients was published with little comment on methods of patient selection or of posttransplant care. Five years later Starzl and colleagues presented data that argued the opposite case-that those with alcoholic hepatitis and cirrhosis show remarkably high rates of relapse to uncontrolled drinking despite having undergone liver transplantation (see Bonet et al. 1993). How can one find a rational approach between these two extremes? The best answer is a complex one, requiring a careful understanding of the methods of preoperative patient selection and of postoperative care. This article offers a brief overview of the topic; for more detail, see Lucey et al. 1994. Table 1 lists the data from four liver transplant programs.(Table 1 omitted) These programs have reported 1-year abstinence rates among liver transplant recipients who also suffered from preexisting alcohol addiction. All programs reported first-year abstinence rates that approximated 90 percent, a remarkably high frequency when compared with the 30- to 50-percent range reported in alcoholism treatment studies that did not involve a procedure as drastic as liver transplantation (Moos 1990; Vaillant 1983). On the surface, it is easy to conclude that a chronic life-threatening illness, followed by the extreme stress of a lengthy operation and its ensuing recovery, might deter a patient from future drinking. There is the added implication that the patient will not receive another transplant if drinking begins again and results in a second liver failure. A closer look at the programs reveals several common threads. Each program carefully selects and then follows those alcohol-dependent patients for whom the program will agree to provide a liver transplantation. Selection is based in part on the perceived risk that a particular patient will return to uncontrolled alcohol use. The University of Michigan' s liver transplant program has led in the development of selection procedures for alcoholic transplant candidates (Beresford et al. 1990), and each of the other programs incorporates some aspects of these procedures in their own formulations. However, the questions arise: Are there empirical guidelines for predicting long-term remission from alcohol dependence? In particular, does the transplant itself have a positive effect on maintaining abstinence? Currently, there are only partial answers to these questions, which are discussed below. PREDICTING ABSTINENCE Research has shown the following characteristics among patients who are likely to maintain long-term abstinence: (1) self-recognition of alcohol dependence and acceptance of it as a condition to be dealt with, (2) a socially stable living environment, (3) freedom from severe psychiatric disorders, and (4) available resources that facilitate continued abstinence (Beresford 1990; Lucey et al. 1994). Vaillant' s work(1983) is especially pertinent. In an 8-year prospective(2) study, he noted that alcoholics who had been abstinent for 3 years or longer had at least two of four clinical indicators. First, they structured their time with substitute activities that limited the potential time they could spend drinking. Second, they had developed a relationship with a person committed to their well-being who put clear limits on his or her toleration of their drinking. Third, they found a sense of hope or of improved self-esteem in some aspect of their lives that counteracted the often intense guilt they felt as a he result of their pathological alcohol use. Fourth, they suffered some noxious consequence of drinking, such as severe abdominal pain from pancreatic inflammation or an ethanol-disulfiram reaction(3) (see the article by Anton, pp. …


Liver Transplantation and Alcoholism Rehabilitation
THOMAS BERESFORD, M.D.
In the excitement of finding a remark ably high rate of firstyear abstinence among his alcoholic liver transplant patients (Starzl et al. 1988), Dr. Thomas Starzl, the pioneer of transplant surgery in this country, commented to the press that liver transplantation might be the ultimate cure for alcoholism. 1 His study of transplanted alcoholic patients was published with little comment on meth 1 Throughout this article, terms such as "alcohol ad diction," "alcoholism," and "problem drinking" are used. These terms overlap in alcoholism literature; therefore, the wording in each case is based on the terms used in the reference cited. ods of patient selection or of posttrans plant care. Five years later Starzl and colleagues presented data that argued the opposite case-that those with alcoholic hepatitis and cirrhosis show remarkably high rates of relapse to uncontrolled drinking despite having undergone liver transplantation (see Bonet et al. 1993). How can one find a rational approach between these two extremes? The best answer is a complex one, requiring a careful understanding of the methods of preoperative patient selection and of postoperative care. This article offers a brief overview of the topic; for more detail, see Lucey et al. 1994. Table 1 lists the data from four liver transplant programs. These programs have reported 1year abstinence rates among liver transplant recipients who also suf fered from preexisting alcohol addiction. All programs reported firstyear absti nence rates that approximated 90 percent, a remarkably high frequency when com pared with the 30 to 50percent range reported in alcoholism treatment studies that did not involve a procedure as drastic as liver transplantation (Moos 1990;Vaillant 1983). On the surface, it is easy to conclude that a chronic lifethreatening illness, followed by the extreme stress of a lengthy operation and its ensuing recov ery, might deter a patient from future drink ing. There is the added implication that the patient will not receive another transplant if drinking begins again and results in a second liver failure.
A closer look at the programs reveals several common threads. Each program carefully selects and then follows those alcoholdependent patients for whom the program will agree to provide a liver trans plantation. Selection is based in part on the perceived risk that a particular patient will return to uncontrolled alcohol use. The University of Michigan's liver transplant program has led in the development of selection procedures for alcoholic trans plant candidates , and each of the other programs incorporates some aspects of these procedures in their own formulations. However, the questions arise: Are there empirical guidelines for predicting longterm remission from alco hol dependence? In particular, does the

PREDICTING ABSTINENCE
Research has shown the following charac teristics among patients who are likely to maintain longterm abstinence: (1) self recognition of alcohol dependence and acceptance of it as a condition to be dealt with, (2) a socially stable living environ ment, (3) freedom from severe psychiatric disorders, and (4) available resources that facilitate continued abstinence Lucey et al. 1994).
Vaillant's work (1983) is especially pertinent. In an 8year prospective 2 study, he noted that alcoholics who had been abstinent for 3 years or longer had at least two of four clinical indicators. First, they structured their time with substitute activ ities that limited the potential time they could spend drinking. Second, they had developed a relationship with a person committed to their wellbeing who put clear limits on his or her toleration of their drinking. Third, they found a sense of hope or of improved selfesteem in some aspect of their lives that counteract ed the often intense guilt they felt as a result of their pathological alcohol use. Fourth, they suffered some noxious con sequence of drinking, such as severe abdominal pain from pancreatic inflam mation or an ethanoldisulfiram reaction 3 (see the article by Anton, pp. 265-271).
As most liver transplant programs now realize, alcoholic candidates who recog nize their alcohol dependence as a serious and continuing health risk, who have a socially stable environment, and who pos sess most or all of the factors described by Vaillant are unlikely to relapse to alcoholic drinking during the first 12 months after a liver transplant. However, it is not certain whether these factors are the actual cause of relapse prevention in these patients.
For most liver transplant recipients, all the predictive factors that Vaillant eluci dated occur in the natural course of post operative care during the first year (Beres ford et al. 1992). For example, the thought of death as a direct and negatively per ceived consequence of drinking may re inforce abstinence, at least in the months immediately following the transplant proce dure. For most patients, the care of the new liver requires a nearly ritualized ingestion of antiimmune medicines twice daily; along with postsurgery rehabilitation, this be comes a substitute activity that structures time and serves to replace drinking as a primary concern in life. Continued contact with the transplant team postoperatively offers a rehabilitation relationship that bolsters the patient's selfesteem and re inforces the necessity of abstaining from alcohol. Finally, liver transplantation offers a profound sense of hope in providing a second chance at life for an alcoholic whose fate otherwise is certain death. This too results in an improved sense of selfworth for most alcoholic recipients. It is therefore not surprising that most properly selected alcoholdependent liver transplant recipients remain abstinent without exposure to formal alcoholism rehabilitation programs either before or after the operation.

LONGTERM ABSTINENCE
All the patient characteristics described by Vaillant (1983) as favorable to abstinence may be fostered naturally as the transplant team assists the patient in the physical re covery process. However, the frequency and intensity of each patient's contact with the team can be expected to decrease during the course of recovery from the operation. Discussed below is the course of postoperative adjustment among alco holics beyond the first year and its impli cations for sustained abstinence.
The Michigan group (Campbell et al. 1993) provided a brief report on a series of 52 alcoholdependent patients who had undergone liver transplantation. All sub jects were rigorously selected and were considered to be at low risk for alcoholism relapse after surgery. Contrary to the practice at some other programs, however, no fixed period of preoperative sobriety was required. Thirteen patients who died within 6 months from causes not related to alcohol use were excluded from analysis, along with one patient whose preoperative evaluation was not available. The final study group included 38 patients, who were followed for 36 months on average. Statistical analysis determined the likeli hood of posttransplant total abstinence to be 92 percent after 1 year and 74 percent after both 2 and 3 years.
During the 3year term, the majority (69 percent) of subjects remained com pletely abstinent, whereas an additional minority (18 percent) experienced brief drinking relapses. The latter group repre sented seven patients who reported limit ed alcohol consumption for brief periods that did not result in injury, medical complication, or a return to uncontrolled alcohol use. The overall lack of alcoholic relapse and injury in these two groups seemed to be due, in part, to attentive longterm followup care.
A small minority (13 percent) of the subjects returned to uncontrolled drinking over the 3year period. This group includ ed a total of five liver transplant recipients who had suffered severe alcoholic relaps es requiring medical hospitalization; one of them died from transplant rejection because of poor compliance with the antiimmune medicines while drinking. This number of seriously relapsing alco holics was too small to determine whether relapse could be predicted by pretrans plant factors, such as length of sobriety before the initial evaluation. The problem of insufficient numbers of subjects also has hampered other attempts to evaluate the predictive value of such factors (Osorio et al. 1994). Nevertheless, the low rates of severe alcoholism relapse even after 3 years is noteworthy. It argues for continued allocation of liver transplants to carefully selected alcoholdependent candidates and indicates the need to im prove predictive and followup methods.
Both 1 and 3year relapse rates among alcoholdependent liver transplant recipi ents appear to be significantly lower than those reported among nonselected patients attending alcoholism rehabilitation pro grams. The best 1year rates of abstinence among the latter reported in the literature are in the range of 50 percent (Vaillant 1983;Moos et al. 1990), less than the 3 year rate noted above among the transplant patients. This difference may be explained by the combination of three elements: patient selection, the transplant experience, and factors that support longterm absti nence. The longterm data from transplant recipients have not been replicated, how ever, and consist only of a small sample surveyed through followup contacts rather than systematically tracked over time. A larger series of alcoholdependent liver transplant recipients who have been care fully selected, evaluated, and followed through time is needed to establish high rates of posttransplant abstinence as a firm empirical observation and to begin to determine the reasons for it.
Of the 3,000 liver transplants per formed annually in this country, only a minority involve alcoholdependent patients (Lucey et al. 1994). The number of alcoholdependent persons in the Na tion at any time is estimated to be in the several millions. The following findings can be learned from this small, unique patient group and can be generalized to treating the larger population of problem drinking Americans: • Providing drastic or painful medical procedures alone, such as disulfiram treatment, probably will not result in sustained abstinence from alcohol.
• Continuous, active care aimed at providing or nurturing the good out come factors described by Vaillant probably will result in higher than expected abstinence rates if that care can be integrated into a program of ongoing medical surveillance.
• Patients who demonstrate favorable outcome prediction profiles may re quire little in the way of formal alco holism rehabilitation treatment.
• Persons suffering from alcohol depend ence whose outcome prediction profiles match those factors associated with sustained abstinence are probably good risk patients for costly and extraordinary medical procedures of any type.
In the current era of health care reform and reduced spending, some people will argue that alcoholics, by virtue of their alleged vice, do not deserve liver or heart transplantations or other such costly pro cedures. Actual transplant data argue to the contrary and support the case for regarding alcoholism as resembling any other illness in that it is amenable to diag nosis, predictive assessment, and under standing through the methods of careful clinical science. ■ Due to popular demand, these volumes in NIAAA's Research Monograph Series have been reprinted. The monographs present results of stateoftheart research, review the considerable progress achieved by researchers, and focus the direction of future research in these crucial areas.
AlcoholInduced Brain Damage, No. 22 provides a multidisciplinary review of the effects of alcohol on the brain. Topics include the prevalence and general characteristics of alcoholic brain damage, physiological and cognitive abnormalities, and possible mechanisms for determining appropriate therapy.
Alcohol and Interpersonal Violence: Fostering Multidisciplinary Perspectives, No. 24 features discussions by leading alcohol and criminal justice researchers on the problem of alcoholrelated violence from biological, psychological, sociological, and economic perspectives; types of violence, primarily spouse and child abuse; and alcoholrelated violence co occurring with drug abuse or mental disorders.
The Development of Alcohol Problems: Exploring the Biopsychosocial Matrix of Risk, No. 26 presents research across a spectrum of scientific domains, including biology, genetics, psychology, and sociology; reviews what is known about interactions of etiologic factors from at least two of these domains; and discusses the development of comprehensive models of alcoholproblem etiology.
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